to the editor: The article summary titled “Preventing Falls: Which Intervention Is Most Effective?”¹ in the Tips from Other Journals section of American Family Physician reviews a prospective study² that concludes that exercise reduces the risk of falls in elderly persons who live at home. The greatest morbidity from falls is hip fracture, and 90 percent of hip fractures result from falls.³ The reviewed study² is concordant with a cohort study⁴ that suggested a 36 percent reduction in hip fracture risk in older women who maintained physically active lifestyles compared with those who were sedentary (after adjusting for potential confounding variables such as functional status, general health, and other personal habits).

In the reviewed study,² 63.5 percent of persons in the control group had at least one fall during the 18-month study period. Among persons whose intervention included exercise, vision management, and home hazard management, 48.1 percent had at least one fall during the 18-month study period.² Even with interventions, nearly one half of the subjects had at least one fall.

Because of the morbidity from falls, specifically hip fracture, examination of older patients should include assessment for risk of falls. In addition to assessing vision, ambulatory dysfunction may be evident on direct observation of gait. Balance difficulties can be assessed (instability on Romberg testing), as well as quadriceps muscle weakness (observable when rising from a chair, without use of the upper extremities, starting with hips and knees each at 90 degrees flexion).

An intervention that has been demonstrated to dramatically reduce hip fracture risk with falls in high-risk groups is the use of hip protectors.^5,6 The relative hazard of a hip fracture in persons wearing hip protectors was 0.4, which represented a 60 percent reduction in hip fractures. Interestingly, of the 13 hip fractures among subjects in the hip protector intervention group, only four occurred while the subjects were wearing hip protectors. In the hip protector group, four hip fractures occurred in 1,034 falls while subjects were wearing protectors, and nine fractures occurred in 370 falls when subjects were not wearing protectors; this resulted in a relative hazard ratio of 0.2 when wearing hip protectors. Overall, hip protectors would have been staggeringly effective had they been worn faithfully 24 hours per day in the intervention group. No difference was noted in fractures between the groups except for hip fractures. Patients who are at risk of falls should have enough pairs of hip protectors to allow them to wear them continuously, including at night (when a lot of hip fractures occur). The principle behind the use of hip protectors is the same as wearing protective gear when playing various sports.

For my elderly patients, I advise exercise, calcium, vitamin D, avoidance of alcohol and tobacco, home hazard reduction (including excellent lighting, nonskid footwear and non-skid surfaces, and removal of obstructions including throw rugs), visual examinations, dual energy x-ray absorptiometry scans (and subsequent treatment if appropriate), and hip protectors. I currently have elderly patients who describe feeling insecure when not wearing their hip protectors.